ADVANCED BEHAVIORAL HEALTH, INC. Clinical Level of Care Guidelines

Transcription

1 The Clinical Level of Care Guidelines contained on the following pages have been developed as a guide to assist care managers, physicians and providers in making medical necessity decisions about the least restrictive, most appropriate level of care. In accordance with Sections of Connecticut Public Act 13-3, the level of care guidelines contained on the following pages were developed utilizing the following clinical practice guidelines: American Psychiatric Association Clinical Practice Guidelines: more information is available at: American Society of Addiction Medicine Patient Placement Criteria, Third Edition (ASAM: more information is available at American Academy of Child and Adolescent Psychiatry s Child and Adolescent Service Intensity Instrument (CASII): more information is available at A. ACUTE INPATIENT PSYCHIATRIC HOSPITALIZATION Acute Inpatient Psychiatric Hospitalization is defined as inpatient treatment services provided in a licensed general or private psychiatric or state hospital offering a full range of diagnostic and therapeutic services with capability for emergency implementation of life-saving medical and psychiatric interventions. Services are provided in a highly structured, contained setting where there is availability of intensive monitoring and observation for patient safety. Assessment for an appropriate level of continuing care begins at the time of admission to this level of care and should also identify the presence, or lack of, available community supports necessary to promote recovery. 1. The individual has a psychiatric or co-occurring substance use disorder diagnosis(es) consistent with the most current version of the Diagnostic and Statistical Manual of Mental Disorders; AND 2. Present symptoms place the individual at imminent risk of danger to self or others, as evidenced by a plan that has or would result in risk of harm to self or others and the urgency of the plan requires an inpatient structured setting that provides 24-hour monitoring and clinical intervention; OR 3. A recent suicide attempt with a degree of lethal intent or attempt made while intoxicated, along with evidence of continued impulsivity or inability to contract for safety; OR 4. Acute symptoms of psychosis that are assessed as placing the individual at imminent risk of danger to self or others, or have not responded to treatment in a less intensive setting, and require an inpatient structured setting that provides 24-hour monitoring and clinical intervention; OR 5. Acute impairment is present that has resulted in grave disability, as evidenced by a marked decrease in the level of daily functioning (work, family, activities of daily living) that renders the individual incapable of caring for himself or herself, and requires the interventions available in a 24-hour setting to address; OR 6. Evidence of risk-taking or self-injurious behaviors that create increasing danger to self or others and require immediate intervention and a highly structured setting to prevent further deterioration or harm to self or others. Page 1 of 14

2 ADVANCED BEHAVIORAL HEALTH, INC. 1. The individual continues to require the services provided in an acute inpatient hospital setting including structured treatment and 24-hour intensive monitoring and his/her condition would deteriorate rapidly outside of the current setting; AND 2. The individual in care requires constant or frequent monitoring for safety of self or others; AND 3. The individual continues to need close medical monitoring to adjust the dosage(s) of psychotropic medication and the medication dosage adjustment cannot be done safely or adequately in a less intensive setting; OR 4. Continued intensive interventions are needed to address impulsive, disruptive or self-injurious behavior(s), and could not safely or adequately be addressed in a less intensive setting, OR 5. The individual continues to be assessed as gravely disabled and has not yet responded to the interventions made or an alternative care setting or supports are not available; OR 6. The individual s symptoms have not yet responded to the therapeutic interventions made, including psychotropic medication; there is evidence of ongoing active management and adjustment of therapeutic interventions to address lack of progress. B. PSYCHIATRIC PARTIAL HOSPITALIZATION Psychiatric Partial Hospitalization is an ambulatory service provided in a general or private psychiatric hospital, freestanding mental health treatment facility, or a state-operated facility that involves ambulatory intensive psychiatric or co-occurring services. The service provides individuals no less than four (4) hours per day, three (3) to five (5) days per week, of clinically intensive programming based on an individualized recovery plan. Services are designed to provide treatment to individuals who are stepping down from acute care or to avert acute hospitalization, and are designed to enhance an individual s level of independent functioning. As with acute inpatient psychiatric hospitalization, assessment for an appropriate level of continuing care begins at the time of admission to this level of care and should also identify the presence, or lack of, available community supports necessary to promote recovery. 1. The individual has a psychiatric or co-occurring substance use disorder diagnosis(es) consistent with the most current version of the Diagnostic and Statistical Manual of Mental Disorders; AND 2. The individual is at risk for inpatient hospitalization due to acute symptoms that markedly interfere with level of daily functioning (work, family, activities of daily living) and/or place the individual at risk of harm to self or others but are assessed as manageable in this setting; OR 3. The individual has recently been discharged from an acute inpatient psychiatric hospitalization and requires a period of intensive monitoring and intervention to sustain gains made in the inpatient setting, or to prevent a rapid symptomatic deterioration and readmission; OR 4. The individual has been experiencing a progressive, marked decline in the level of functioning and movement from baseline functioning and requires this level of care to prevent further deterioration. Page 2 of 14

3 ADVANCED BEHAVIORAL HEALTH, INC. 1. The individual s symptoms continue to place him/her at risk for inpatient hospitalization due to continued acute symptoms that interfere with the ability to maintain a level of daily functioning (family, work, activities of daily living) and have not improved since admission, but are assessed as manageable at this level of care; OR 2. The individual continues to exhibit acute symptoms that require intensive monitoring and intervention to sustain gains made or prevent rapid decompensation and re-hospitalization; OR 3. The individual has made little progress in spite of intensive monitoring and intervention, is expected to respond to the planned interventions, and rapid decompensation is likely if continued treatment is provided in a less intensive level of care. C. INTENSIVE OUTPATIENT MENTAL HEALTH Intensive Outpatient (Mental Health) is an ambulatory service provided in a general or private psychiatric hospital, state-operated facility, or an outpatient psychiatric treatment facility. This service provides treatment for three to four (3 4) hours per day, three to five (3 5) days per week. Services provided include evaluation, group and individual therapy and treatment is based on comprehensive, individualized recovery plan. Treatment focuses on reducing symptoms, improving overall functioning, preventing relapse, and decreasing the need for a more intensive level of care. Services provided at this level of care should include consideration and development of a continuing care plan that addresses the services that will be needed at the time of discharge from this level of care. 1. The individual has a psychiatric or co-occurring substance use disorder diagnosis(es) consistent with the most current version of the Diagnostic and Statistical Manual of Mental Disorders; AND 2. The current symptoms experienced by the individual seeking admission are assessed as moderate to severe and require the therapeutic interventions available at this level of care to prevent further deterioration and need for admission to a higher level of care; OR 3. The individual has experienced a recent exacerbation in psychiatric or co-occurring symptoms resulting in moderate impairment in daily functioning that require more frequent monitoring and intervention than available in traditional outpatient care; OR 4. The individual is stepping down from services provided in partial hospital treatment and continues to require frequent therapeutic intervention to continue to assist in improving overall functioning and avoiding rapid decompensation; OR 5. Despite ongoing treatment in an outpatient level of care, the individual s symptoms of psychiatric or co-occurring disorders have continued to worsen and require a period of more intensive monitoring and intervention to improve level of daily functioning. Page 3 of 14

4 ADVANCED BEHAVIORAL HEALTH, INC. 1. The individual s symptoms have not yet responded to the therapeutic interventions made,; there is evidence of ongoing active management and adjustment of therapeutic interventions to address lack of progress and relapse would be likely without the interventions provided at this level of care; OR 2. There has been identified improvement in the symptoms, but continued intensive intervention is needed at this level of care to solidify gains made and prevent relapse; OR 3. Symptoms present at admission have worsened or accompanied by recent or repeated relapse to use of substances, but are assessed as manageable at this level of care with continued intensive intervention. D. OUTPATIENT MENTAL HEALTH Outpatient mental health treatment is a short term, problem focused ambulatory service provided by appropriately licensed professionals in a general or private psychiatric hospital, psychiatric outpatient clinic, or state-operated facility. This level of care includes the evaluation, diagnosis, and/or treatment of individuals, couples, or families. 1. The individual has a psychiatric or co-occurring substance use disorder diagnosis(es) consistent with the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); AND 2. The individual is currently experiencing symptoms that are consistent with the diagnosis of psychiatric or co-occurring disorder and the symptoms are likely to improve with the provision of outpatient services; AND 3. The individual is capable of benefitting from treatment services and demonstrates an acknowledgement of need for treatment and readiness to change. 1. The individual s symptoms have not responded to the therapeutic interventions made, which may or may not include adjustment of psychotropic medication; adjustment of therapeutic interventions are expected to be implemented in the near future; AND/OR 2. The individual s symptoms have responded to the therapeutic interventions made but further stabilization is necessary and improvement is expected; AND/OR 3. The individual s symptoms have worsened and a more intensive level of care is recommended but not yet available; AND 4. The treatment provided is not solely supportive or geared toward maintaining the current status. Page 4 of 14

5 E. MEDICALLY-MANAGED INPATIENT DETOXIFICATION (ASAM LEVEL IV-D) Medically-managed inpatient detoxification is an inpatient behavioral health service provided in a general or private psychiatric hospital or state-operated facility when the individual requires rapid treatment for a substance abuse disorder accompanied by a serious or dangerous co-occurring medical or psychiatric condition. Medically-managed inpatient detoxification is used when on-site 24-hour medical and nursing supervision is required to deliver intensive evaluation, medication titration, symptom stabilization and intensive, brief treatment. Services provided at this level of care should include consideration and development of a continuing care plan that addresses the services that will be needed at the time of discharge from this level of care. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as severe and continuous consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The individual is experiencing signs and symptoms of severe withdrawal, or severe withdrawal is imminent based on the history and the individual requires 24-hour medical and nursing intervention; AND 3. There is a history of daily use at higher than therapeutic levels of sedative-hypnotics such as benzodiazepines for four (4) or more weeks prior to admission, alone or in combination with other substances; OR 4. The individual has been consuming alcohol daily and requires monitoring more frequently than hourly for symptoms of gross intoxication or severe withdrawal syndrome which may include seizure activity or delirium tremens (DTs); OR 5. Symptoms of a concurrent medical or psychiatric disorder are present and there is potential that symptoms will be exacerbated by the withdrawal syndrome and require 24-hour medical and nursing supervision; OR 6. Signs of stimulant intoxication or withdrawal are present that require monitoring more frequently than hourly; symptoms may include severe depression or suicidality, impulsive behavior or psychosis; OR 1. The individual continues to receive tapering doses of medication to address signs and symptoms of withdrawal; AND 2. The individual has a medical condition that may be exacerbated by substance withdrawal and requires 24-hour medical and nursing supervision; OR 3. Acute psychiatric symptoms such as severe depression, suicidality, impulsivity or psychosis are present that complicate the withdrawal process and require 24-hour medical and nursing supervision. Page 5 of 14

6 F. MEDICALLY-MONITORED INPATIENT DETOXIFICATION (ASAM Level III.7-D) Medically-monitored inpatient detoxification is an inpatient service provided in a residential detoxification facility or state-operated facility that involves medically directed treatment for a substance use disorder. This service is provided when 24-hour nursing supervision is needed, with the availability of a physician to provide on-site evaluation on a daily basis for a medically directed substance use disorder evaluation and withdrawal management. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as severe and continuous, consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The withdrawal syndrome is assessed as manageable at this level of care; AND 3. The individual is experiencing symptoms of moderate to severe withdrawal; OR 4. There is evidence that moderate to severe withdrawal is imminent based on history of substance intake, age, previous withdrawal history and present condition; AND 5. Co-occurring medical or psychiatric disorders are present that complicate the withdrawal process but are assessed as manageable at this level of care; OR 6. There is high likelihood that the individual will not successfully complete the detoxification process at a less intensive level of care based on a recent history of ambulatory treatment failure or lack of community supports necessary to successfully complete ambulatory detoxification. 1. The individual continues to receive tapering doses of medication to address signs and symptoms of withdrawal; AND 2. The individual continues to require 24-hour nursing supervision; AND 3. The individual has a medical or psychiatric condition that complicates the withdrawal process or requires 24-hour nursing supervision; OR 4. There is high likelihood that the individual will not successfully complete the detoxification process is treatment is provided in a less intensive level of care. G. SUBSTANCE ABUSE INTENSIVE RESIDENTIAL TREATMENT (ASAM Level III.7) Intensive Residential Treatment is an inpatient service that is delivered in a 24-hour residential treatment setting to individuals with a substance use disorder or co-occurring disorders. A minimum of thirty (30) hours per week of substance use disorders treatment services are provided based on a comprehensive, individualized recovery plan. Services provided at this level of care should include consideration and development of a continuing care plan that addresses the services that will be needed at the time of discharge from this level of care. Page 6 of 14

7 1. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe with or without co-occurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The individual s substance use disorder, in combination with an identified medical condition, place the individual at increased risk of serious damage to his/her physical health but are assessed as manageable at this level of care; OR 3. Symptoms related to a co-occurring psychiatric disorder have interfered with the individual s efforts at abstinence; the individual requires a 24-hour structured setting and intensive interventions to address recovery; OR 4. The individual s level of functioning due to the impact of his/her substance use disorder have deteriorated to the degree that the individual is unable to focus on recovery efforts without intensive motivational interventions and structured environment; OR 5. The individual has experienced marked deterioration in social functioning or activities of daily living and requires active monitoring for a co-occurring psychiatric disorder; OR 6. The individual is assessed as exhibiting impulsive or high-risk behaviors as a result of a substance use disorder or co-occurring disorders and is at imminent risk for relapse that will be accompanied by serious behavioral consequences without 24-hour monitoring and therapeutic intervention. 1. Progress in treatment has been hampered by the individual s limited insight into the consequences of use or frequent, intense cravings to use; intensive motivational strategies are needed to address; OR 2. There has been documented progress towards identified recovery goals; the individual continues to require 24-hour monitoring and therapeutic intervention to solidify gains made to avert rapid relapse; OR 3. Behaviors related to chronic sequelae of substance use or a co-occurring psychiatric disorder continue to interfere with social functioning and activities of daily living; improvement is expected with ongoing management and active adjustment of therapeutic interventions; OR 4. There has been documented progress towards identified recovery goals; symptoms related to a medical disorder continue to require 24-hour monitoring and intervention not available in a less intensive level of care. H. INTERMEDIATE RESIDENTIAL TREATMENT (ASAM LEVEL III.5) Intermediate Residential Treatment is an inpatient service delivered in a structured recovery environment to individuals with substance use disorders with or without the presence of a co-occurring psychiatric disorder. Programs identified as clinically managed medium-intensity treatment (ASAM Level III.5) provide services to individuals who have marked social and psychological problems associated with a substance use disorder that require long-term treatment. Treatment in this level of care is primarily focused on readiness to change, either from a viewpoint of recognizing their substance use or consequences of use or toward developing a sense of personal responsibility and need for positive change. Page 7 of 14

8 ADVANCED BEHAVIORAL HEALTH, INC. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe with or without co-occurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The individual needs monitoring of psychiatric/emotional symptoms concurrently with addiction treatment and is assessed as stable enough to participate in therapeutic interventions and benefit from treatment. 3. The individual s insight into the need for continuing care is impaired as a result of chronic substance use with or without a co-occurring psychiatric disorder, increasing the risk of relapse; OR 4. The individual s symptoms and functional limitations are assessed to be at a level that he/she is unlikely to maintain abstinence or mood stability if services were provided in a non-residential treatment setting; OR 5. The individual has a co-occurring psychiatric disorder that has begun to stabilize but distractibility, negative emotions or generalized anxiety place the individual at risk outside a 24- hour structured environment. 1. Progress in treatment has been slowed by cognitive deficits or other sequelae of chronic substance use; continued treatment in a structured inpatient environment is needed; OR 2. Symptoms of a co-occurring psychiatric disorder have required continued stabilization and have slowed the individual s progress in treatment; OR 3. Progress has been slowed by the individual s severe deficits in interpersonal and coping skills; there is evidence of ongoing active management and adjustment of therapeutic interventions to address lack of progress and relapse would be likely without the interventions provided at this level of care; OR 4. There has been documented progress towards identified recovery goals; the individual continues to require a 24-hour structured setting to solidify gains made to avert relapse. I. SUBSTANCE ABUSE LONG-TERM CARE Substance Abuse Long Term Care is an inpatient service delivered in a structured recovery environment to individuals with substance use disorders with or without the presence of a co-occurring psychiatric disorder. Programs identified as clinically population-specific medium intensity residential treatment provider (ASAM Level III.3) provide services to individuals who have a level of impairment, including cognitively as a result of chronic substance use or addictive behaviors that is such that treatment provided in a non-residential setting is not feasible or effective. Cognitive impairment may be assessed as temporary or permanent and requires a slower paced, more concrete and repetitive focus. 6. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe with or without co-occurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND Page 8 of 14

9 7. Despite severe consequences or effects related to the addictive disorder or psychiatric disorder, the individual has marked difficulty recognizing the relationship between the substance use or doesn t recognize the need for help; OR 8. The individual s insight into the need for continuing care is impaired as a result of chronic substance use with or without a co-occurring psychiatric disorder, increasing the risk of relapse; OR 9. The individual s pattern of continued/chronic use places him/her at risk of danger to self or others and treatment is needed at this level of care to provide motivational strategies to improve the individual s readiness to change; OR 10. The individual s perception affects his or her ability to make behavior changes without repeated, structured, clinically-directed motivational interventions delivered in a 24-hour structured inpatient setting. This would include the individual externalizing blame for the alcohol and/or drug problem with or without co-occurring psychiatric disorder on external events or sources. II. Continued Stay Criteria 5. Progress in treatment has been slowed by cognitive deficits or other sequelae of chronic substance use; continued treatment in a structured inpatient environment is needed; OR 6. Symptoms of a co-occurring psychiatric disorder have required continued stabilization and have slowed the individual s progress in treatment; OR 7. Progress has been slowed by the individual s severe deficits in interpersonal and coping skills; there is evidence of ongoing active management and adjustment of therapeutic interventions to address lack of progress and relapse would be likely without the interventions provided at this level of care; OR 8. There has been documented progress towards identified recovery goals; the individual continues to require a 24-hour structured setting to solidify gains made to avert relapse. J. SUBSTANCE ABUSE TRANSITIONAL CARE/HALFWAY HOUSE (ASAM LEVEL III.1) Substance Abuse Transitional Care/Halfway House is an inpatient service delivered in a structured recovery environment to individuals with substance use disorders with or without the presence of a cooccurring psychiatric disorder. Programs identified as clinically managed low-intensity residential treatment (ASAM Level III.1) provide at least five (5) hours per week focused on promoting personal responsibility and reintegration into work, education and family life. This level of care is generally indicated for individuals who need time and structure to practice and integrate their coping and recovery skills in a residential, supportive environment. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe with or without co-occurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. Functional deficits such as chronic substance use, addictive behaviors, antisocial behaviors, psychological and/or personality disorders, inadequate anger management that are currently present interfere with the individual s ability to benefit from treatment provided in a less intensive or ambulatory level of care; OR Page 9 of 14

10 3. The individual s insight into the need for continuing care is impaired as a result of chronic substance use with or without a co-occurring psychiatric disorder, increasing the risk of relapse; OR 4. The individual is in need of staff support to maintain engagement in the recovery process while transitioning back to the community; OR 5. The individual has a co-occurring psychiatric disorder that has begun to stabilize but craving, poor coping skills and drug-seeking behaviors places the individual at risk outside a 24-hour structured environment. II. Continued Stay Criteria 1. Progress in treatment has been slowed by cognitive deficits or other sequelae of chronic substance use; continued treatment in a structured inpatient environment is needed; OR 2. Symptoms of a co-occurring psychiatric disorder have required continued stabilization and have slowed the individual s progress in treatment; OR 3. Progress has been slowed by the individual s severe deficits in interpersonal and coping skills; there is evidence of ongoing active management and adjustment of therapeutic interventions to address lack of progress and relapse would be likely without the interventions provided at this level of care; OR 4. There has been documented progress towards identified recovery goals; the individual continues to require a 24-hour structured setting to solidify gains made to avert relapse. K. SUBSTANCE ABUSE PARTIAL HOSPITALIZATION TREATMENT (ASAM LEVEL II.5) Substance Abuse Partial Hospitalization Treatment is an ambulatory service provided in a general or private psychiatric hospital, freestanding behavioral health treatment facility, or a state-operated facility that involves ambulatory intensive substance use or co-occurring psychiatric disorder services. The service provides individuals no less than four (4) hours per day, three (3) to five (5) days per week, of clinically intensive programming based on an individualized recovery plan. Services are designed to provide treatment to individuals who are stepping down from acute care or to avert need for a higher level of care. Assessment for an appropriate level of continuing care begins at the time of admission to this level of care and should also identify the presence, or lack of, available community supports necessary to promote recovery. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe with or without co-occurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The individual s use of substances has resulted in moderate to severe impairment of daily functioning (work, family, activities of daily living) and requires the structure and monitoring of this level of care to interrupt or prevent repeated relapse; OR 3. The individual has recently been discharged from an acute inpatient detoxification and requires a period of intensive monitoring and intervention to sustain gains made in the inpatient setting, or to prevent rapid relapse and readmission; OR Page 10 of 14

11 4. The individual lacks insight into the consequences of relapse and coping skills and has not been able to benefit from services provided at a less intensive level of care. 1. Despite active involvement at this level of care, there is evidence that symptoms related to the substance use disorder or co-occurring disorder have increased to avert continued deterioration and need for a higher level of care; OR 2. Progress has been slowed by the individual s limited insight; additional clinical interventions in a structured setting are necessary to prevent rapid decompensation and relapse; OR 3. Symptoms of a co-occurring psychiatric disorder have required intensive intervention which may also include pharmacologic management and have slowed the individual s ability to benefit from this level of care; improvement is expected within a brief period of time; OR 4. The individual has not yet responded to treatment and symptoms related to the substance use disorder have worsened; active interventions are taking place to identify a more intensive level of care (i.e., residential treatment). L. INTENSIVE OUTPATIENT TREATMENT - SUBSTANCE ABUSE (ASAM LEVEL II.2) Intensive Outpatient Treatment for substance use disorders is an ambulatory substance abuse service provided in a general or private psychiatric hospital, state-operated facility, or facility appropriately licensed to provide this level of care. This level of care provides clinically intensive services to individuals three to four (3 4) hours per day, three to five (3 5) days per week based on an individualized recovery plan. Treatment focuses on development of an individualized relapse prevention plan, and on enhancing the individual s ability to initiate and manage behavior that promotes recovery. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe with or without co-occurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The individual has been recently discharged from an inpatient level of care and is in need of structured clinical intervention in an intensive setting to solidify gains made and prevent relapse; OR 3. The individual s ability to maintain abstinence has been impaired by the lack of insight into consequences of substance use accompanied by symptoms of a co-occurring psychiatric disorder and requires intensive motivational interventions and monitoring not available in a less intensive level of care; OR 4. Despite attempts at treatment in a traditional outpatient setting, the individual has been unable to remain abstinent and requires a more structured and intensive treatment setting to address issues and/or prevent further decompensation. Page 11 of 14

12 ADVANCED BEHAVIORAL HEALTH, INC. 1. Despite active involvement at this level of care, there is evidence that symptoms related to the substance use disorder or co-occurring disorder have increased and continued treatment is necessary to avert continued deterioration and need for a higher level of care; OR 2. Progress has been slowed by the individual s limited insight; additional clinical interventions in a structured setting are needed to prevent relapse and need for a more intensive level of care; OR 3. Symptoms of a co-occurring psychiatric disorder have slowed the individual s ability to benefit from this level of care; improvement is expected within a brief period of time; OR 4. The individual has not yet responded to treatment and symptoms related to the substance use disorder have worsened; active interventions are taking place to identify a more intensive level of care (i.e., PHP, residential treatment). M. METHADONE MAINTENANCE (Medication-Assisted) TREATMENT (ASAM OPIOID MAINTENANCE TREATMENT Methadone Maintenance is an ambulatory service provided in a licensed facility to offer chemical maintenance treatment to opiate addicted individuals. This service involves daily admission of methadone prescribed at individualized doses, regularly scheduled psychosocial treatment sessions, health education, and assessment of needs including those related to accessing recovery supports. 1. The individual meets the diagnostic criteria for a substance use disorder categorized as moderate or severe or co-occurring disorders consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. There are no current medical, emotional, behavioral and/or cognitive conditions or complications that would prevent safe treatment at this level of care; AND 3. The individual is under age 18 and has had at least two (2) documented unsuccessful attempts at short-term detoxification or drug-free treatment in the past 12 months, with the consent of a parent or legal guardian; OR 4. The individual has a documented history of 1 year of opioid addiction; OR 5. The individual has less than 1 year of documented opioid addiction but is currently pregnant; OR 6. The individual has had previous methadone maintenance treatment and was discharged from the previous treatment within the past two (2) years; OR 1. The individual is compliant with treatment and the recommendations of the treatment team; OR 2. There is evidence of the individual s noncompliance with ongoing treatment, and there is evidence that specific interventions have been identified and taken to address the lack of Page 12 of 14

13 compliance. Specific measures may include: modification of Methadone dosage, involvement in individual and/or group counseling sessions, random drug screens, etc.; OR 3. The individual is pregnant and continued administration of Methadone is necessary to prevent acute withdrawal and complications to the fetus; OR 4. The member is noncompliant with treatment and requires a more intensive level of service, and admission to a more intensive level of care is expected within the next thirty (30) days. N. AMBULATORY DETOXIFICATION (ASAM LEVEL I.D) Ambulatory Detoxification is a service provided in a general or private psychiatric hospital, stateoperated facility, or other appropriately licensed service provider to offer ambulatory chemical detoxification. This service uses prescribed medication for the systematic reduction of physical dependence upon a substance for individuals assessed as able to tolerate outpatient detoxification. This service involves the assessment of needs, including those related to recovery supports, including engaging the individual in the need for continuing care after the detoxification process has been completed. 1. The individual meets the diagnostic criteria for a substance use disorder consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. There are no medical conditions currently or by history that would interfere with safe detoxification from substances provided at this level of care; AND 3. The individual does not have a past history of severe withdrawal complications such as seizures or delirium tremens; AND 4. The individual is exhibiting symptoms of mild to moderate withdrawal; symptoms are assessed as manageable at this level of care; OR 5. There is potential for symptoms of moderate withdrawal, as evidenced by history based on usage history, age and past withdrawal history. 1. The individual continues to receive a tapering dose of detoxification medication to avert symptoms of moderate withdrawal and requires continued monitoring and therapeutic interventions to successfully withdraw from substances; OR 2. The individual s symptoms of withdrawal continue to prompt use of medications other than detoxification medication to address symptoms of discomfort related to withdrawal as well as other clinical interventions to safely complete the detoxification and transition to continuing care. Page 13 of 14

14 O. OUTPATIENT SUBSTANCE ABUSE TREATMENT (ASAM LEVEL I) Outpatient substance abuse treatment is a short-term ambulatory service provided in a general or private psychiatric hospital, outpatient clinic, state-operated facility, or other facility or professional licensed to offer outpatient treatment. This service includes professional directed evaluation, assessment and treatment provided in regularly scheduled sessions to individuals with substance use or co-occurring disorders. 1. The individual meets the diagnostic criteria for a substance use disorder with or without cooccurring psychiatric disorder(s) consistent with the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM); AND 2. The individual is currently experiencing symptoms that are consistent with the diagnosis of substance use or co-occurring psychiatric disorder and the symptoms are likely to improve with the provision of traditional outpatient services; AND 3. The individual is capable of benefitting from treatment services and demonstrates an acknowledgement of need for treatment and readiness to change. 1. The individual s symptoms have not responded to the therapeutic interventions made, which may or may not include adjustment of psychotropic medication; adjustment of therapeutic interventions are expected to be implemented in the near future; AND/OR 2. The individual s symptoms have responded to the therapeutic interventions made but further stabilization is necessary and improvement is expected; AND/OR 3. The individual s symptoms have worsened and a more intensive level of care is recommended but not yet available; AND 4. The treatment provided is not solely supportive or geared toward maintaining the current status. REFERENCES 1. Practice Guidelines for the Treatment of Psychiatric Disorders (Compendium 2006). American Psychiatric Association. Washington, DC Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, Third Edition. American Psychiatric Association. Washington, DC Practice Guidelines for the Treatment of Patients with Schizophrenia, Second Edition. American Psychiatric Association. Washington, DC Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association. Washington, DC Mee-Lee D, Ed., The ASAM Treatment Criteria for Addictive, Substance-Related and Co- Occurring Conditions, Third Edition. American Society of Addiction Medicine, Chevy Chase, MD Electronic Code of Federal Regulations, Title 42, Part 8.12, Federal Opioid Treatment Standards. [66 FR 4090, Jan. 17, 2001, as amended at 68 FR 27939, May 22, 2003; 77 FR 72761, Dec. 6, Page 14 of 14